SURGICAL ASSOCIATES OF MACOMB

PATIENT HEALTH HISTORY

Name:     Date:

Age:        Date of Birth:

 Chief Complaint:
 

PAST MEDICAL HISTORY (CHECK ALL CONDITIONS YOU HAVE OR HAVE HAD IN THE PAST):

  AIDS/HIV    Emphysema Hypoglycemia
  Alcoholism    Epilepsy Pneumonia
  Anemia       Gastroesophageal Reflux Prostate Disease
  Anorexia/bulimia      Glaucoma   Psychiatric Care
  Appendicitis           Gout   Rheumatic Fever
  Arthritis     Heart Disease/MI  Stroke
  Asthma    Hepatitis Thyroid Disease
  Bleeding disorders     Hernia   Blood transfusions
  Blood clots     High blood pressure  Tuberculosis
  Breast lump        High cholesterol   Ulcers
  Cancer    Kidney Disease Other
  Cataracts         Liver Disease   Chemical Dependency
   Migraine Headaches   Diabetes        Multiple Sclerosis

 PAST SURGICAL HISTORY:

Date Operation Surgeon

PAST GYNECOLOGIC/OBSTETRIC HISTORY:

Age menstruation started                                                         Date of last mammogram
Age at menopause                                                                     Normal                    Abnormal
 Number of pregnancies               
Number of children                                                                 Date of last Pap smear    
Date of last menses                                                                  Normal                    Abnormal

ALLERGIES:

Name Type of Reaction Please check if you are allergic to
  Latex
  IV dye
 
 
 
 

 Name:

 MEDICATIONS (include over the counter medicines, vitamins, minerals, herbals):

Name: Dosage: Frequency:

 SOCIAL HISTORY (check any substances you use or have used in the past):

 Caffeine (current user)
  Caffeine (past user)
 Tobacco (current user)
 Tobacco (past user)
           Number of packs per day
        Duration    
Marijuana (current user)
 Marijuana (past user) 

alcohol (current user)
 alcohol (past user)
        frequency of use
        amount
 IV drugs (current user)
 IV drugs (past user)
 cocaine (current user)
 cocaine (past user)

 

 

 

 FAMILY HISTORY (please provide health history about your family):

Relation Medical Conditions Alive (Y/N) Age at Death Cause of Death
Father
Mother
Siblings
 
 
 

REVIEW OF SYSTEMS (check any symptoms you are currently experiencing)

Weight loss Nausea  Difficulty swallowing
Weight gain Vomiting  Hearing loss
Heartburn  Fatigue Headaches
Fever/chills    Diarrhea  Blood in urine   
Chest pain   Rectal bleeding   Numbness in extremities
Palpitations  Vomiting blood Depression  
Constipation Painful bowel movements Other     
Hoarseness  Painful urination  
Joint pain Convulsions/seizures       
Shortness of breath Frequent urination   
Swelling of extremities Lack of bladder control    
Easy bruising Sinus problems  
Frequent cough Abdominal pain  
Wheezing Changes in vision  
Bloody cough Muscle pain/cramps  
Loss of appetite  Back pain  
Forgetfulness/memory loss Dizziness/lightheadedness   
               

Signature                                                                                           Date                                        

Please complete and print this form and bring with you to your appointment